Conjoined Twins Successfully Separated at Lucile Packard Children’s Hospital Stanford

Two-year-old twin sisters Erika and Eva Sandoval are recovering in the
pediatric intensive care unit following their Dec. 6 separation surgery.

STANFORD, Calif.–(BUSINESS WIRE)–Conjoined twins Erika and Eva Sandoval were successfully separated at Lucile
Packard Children’s Hospital Stanford
in a 17-hour surgery that began
Dec. 6 and stretched into the early morning hours of Dec. 7. Prior to
separation, the two-year-old twins of Antelope, California, shared much
of their lower body.

“They did very well,” said lead surgeon Gary
Hartman, MD
, a clinical professor of surgery at the School of
Medicine. “I’m very pleased with the outcome.”

The Sandoval girls are the seventh pair of conjoined twins Hartman has
separated and the fifth separation surgery he has done at Stanford. The
last separation at Packard Children’s was performed in 2011.

“It’s amazing how strong these girls are and it’s amazing what their
team performed,” said Aida Sandoval, the twins’ mother. “Seeing them now
in the ICU, you look at them and think ‘You’re missing your other half’
but we know that this is the right path for them: to be independent,
have the chance to succeed and explore on their own everything the world
has to offer.”

Erika and Eva are now in stable condition in the pediatric intensive
care unit, where they are expected to recover for about two weeks. Their
physicians anticipate that they will spend an additional two weeks in
the hospital before they go home. They are sharing a hospital room but
are in separate beds.

Prior to separation, Erika and Eva were thoraco-omphalo-ischiopagus
twins, positioned facing each other and joined from the lower chest and
upper abdomen level down. They had separate hearts and lungs but shared
their diaphragm muscle and some anatomical structures below the
diaphragm. They each had a stomach but had other connections within
their digestive system. They had one liver, one bladder, two healthy
kidneys and three legs.

“Before separation, you could think of their anatomy as two people above
the rib cage, merging almost into one below the bellybutton,” said
plastic and reconstructive surgeon Peter
Lorenz, MD
, professor of surgery at the School of Medicine, who led
the reconstructive phase of the twins’ separation.

The separation team included about 50 people. By the time the twins go
home, more than 100 hospital caregivers will have helped with their
case, including many physicians and nurses who took care of Aida during
her high-risk pregnancy and who cared for the twins as newborns.

Separation day

The girls were wheeled into the operating room shortly after 7 a.m. Dec.
6, where they were carefully anesthetized by a team of six
anesthesiologists, three per twin, led by Gail
Boltz, MD
, clinical professor of anesthesiology, perioperative and
pain medicine at the School of Medicine. Once the twins were
anesthetized, the team placed central and arterial lines to enable blood
transfusions and deflated the three saline-filled tissue expanders that
had been used to generate new skin to help cover their separation site.
The first incision was made at 11 a.m.

Erika and Eva had received comprehensive CT and MRI scans as part of the
preparation for surgery, and these were used to print 3-D models of
their pelvic bones and blood vessels to help plan the division. But
there were still questions about details of the girls’ shared anatomy,
which the team spent about an hour resolving at the beginning of the

“We had amazing information from our radiology colleagues, but even with
that there were some surprises,” Hartman said. “There was only one large
intestine. It appeared that it all belonged to Eva but had some blood
supply from Erika, so we had to do some testing in the operating room to
clarify that.” During surgery, the team also found that the girls shared
a single pericardial sac around their separate hearts, and that each
child had her own gallbladder.

Once the exploratory phase was complete, the team divided the twins’
liver and split their gastrointestinal and urinary tracts. The girls’
single bladder was divided and made into two bladders, and each child
received a colostomy. The pelvic bones were then divided.

The biggest risk that the surgical team had anticipated prior to
separation was excessive bleeding from small, diffuse blood vessels and
from the pelvic bones, but fortunately, the twins did not experience
excess blood loss. The final incision that officially separated Eva and
Erika was made by James
Gamble, MD
, professor of orthopedic surgery, and Matias
Bruzoni, MD
, assistant professor of pediatric surgery, at 4:34 p.m.
Dec. 6.

For the first time, separate rooms

After the girls were separated, Eva was wheeled to an operating room
across the hall, the first time in their lives that the twins had been
in separate rooms. Lorenz led the team that performed Eva’s
reconstructive surgery, which took until 12:30 a.m. Dec. 7. Erika’s
reconstructive surgery, led by pediatric plastic and reconstructive
surgeon Rohit
Khosla, MD
, assistant professor of surgery at the School of
Medicine, was completed an hour later. Eva had enough skin from the
tissue expanders to completely close her surgical site. To help complete
Erika’s reconstruction, the bones from the girls’ third leg were
removed, and skin and muscle from the leg were used to close Erika’s
abdominal wall. The surgeons had considered keeping the leg with Erika
if it was not needed for reconstruction, but it would likely not have
been useful for walking because of its abnormal anatomy.

Throughout the surgery, the team used a 3-D virtual-reality imaging
system that was recently introduced at Packard Children’s. The imaging
system allows the surgeons to put on 3-D glasses and view an image that
can be rotated and manipulated to better see the anatomy detected in
prior radiology scans. Pediatric radiologist Frandics
Chan, MD
, associate professor of radiology at the School of
Medicine, assisted the surgeons with the new technology.

“When it became clear that we needed to use the third leg for
reconstruction, Dr. Chan came in to the operating room and showed the
team exactly where the blood vessels supplying the leg were located so
that they could plan how to protect the blood supply to the leg,”
Hartman said.

Now that Eva and Erika are separated, each child is missing about
one-third of the abdomen and has one kidney and one leg. Both girls are
expected to remain sedated and on ventilators for another day or two to
help with pain control.

As Erika and Eva heal and grow, the team will assess whether any further
reconstructive surgeries would be helpful for either child. “We set them
up so that if everything heals well, they may not need any further
surgery,” Hartman said.

The expertise of many Stanford pediatric specialists contributed to the
separation’s successful outcome, with surgeons specializing in
gastrointestinal, orthopedic, urologic and plastic and reconstructive
surgery all contributing. “We have both the subspecialist surgeons we
needed and the appropriate anesthesia and nursing expertise to take care
of Eva and Erika during and after their separation,” Lorenz said. “We do
high-risk surgical cases often, and our experience counts a great deal
for a case like this.”

“The results are as good as we could have asked for,” Hartman concluded.

“I can’t say enough about all the members of the care team, the
surgeons, physicians, nurses and all the specialists. Every incision
they made, I know God was there,” Aida Sandoval said. “We know Erika and
Eva are bound for great, amazing things.”

Sidebar: Case history and preparing for birth

Conjoined twins are rare. They occur in 1 in 30,000 to 1 in 200,000
births. When Aida Sandoval was referred to Packard Children’s midway
through her 2014 pregnancy with Erika and Eva, the hospital’s Fetal and
Pregnancy Health Program immediately brought together physicians from high-risk
, neonatology,
and other specialties to form an expert group that could
care for Aida and both babies. Aida had high blood pressure, which
further complicated an already difficult pregnancy.

“In addition to our multidisciplinary team’s very close monitoring of
Aida and our vigilant evaluation of fetal health, we had to create a
detailed delivery plan that included simulation of potential delivery
scenarios,” said Susan
Hintz, MD
, professor of neonatal and developmental medicine and
medical director of the Fetal
and Pregnancy Health Program
. After performing fetal MRI scans to
investigate the babies’ anatomy, the team brought in Louis
Halamek, MD,
professor of neonatal and developmental medicine and
director of the Center for Advanced Pediatric and Perinatal Education at
Packard Children’s, who made a specialized conjoined mannequin that
resembled the twins as closely as possible to facilitate realistic

“Because the girls are situated facing each other, we knew that if they
were delivered prematurely and had respiratory issues, the physical
constraints of how they are connected could pose challenges to
successful resuscitation, including intubation,” said Hintz, who is also
the Robert L. Hess Family Professor. The team practiced potential
delivery scenarios with the mannequin, including intubating, or
inserting breathing tubes. Fortunately, when the girls were delivered by
cesarean seven weeks early on Aug, 10, 2014, they were able to breathe
without intubation, instead requiring positive pressure and oxygen via
face masks. Nevertheless, Eva and Erika were fragile. They were
hospitalized at Packard Children’s for their first 6 months of life, and
then followed by several physicians as they grew big enough to be

The hospital plans to hold a press conference on Dec. 8 at 12:30pm PST,
contact the media relations team for details.

About Stanford Children’s Health and Lucile Packard Children’s
Hospital Stanford

Stanford Children’s Health, with Lucile Packard Children’s Hospital at
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News & World Report Best Children’s Hospitals Honor Roll
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Lucile Packard Children’s Hospital Stanford
Samantha Dorman,
DeTrempe, 650-721-8527